Idiopathic scrotal edema

IDIOPATHIC J. P. EVANS, H.McC.

SCROTAL EDEMA

F.R.C.S.

SNYDER,

M.D.

Department of Pediatric Urology, Alder Hey Children’s Hospital, Liverpool, England

ABSTRACT - An eight-year experience consisting of 30 cases of idiopathic scrotal edema has been analyzed. The condition is characterized by a minimally painful scrotal swelling produced by subcutaneous edema. A normal testis and cord enable one to differentiate it from some other causes of scrotal swelling such as torsion of the testis and epididymo-orchitis. A connection with trauma, periurethral disease, or streptococcal disease appears unlikely. A localized allergic phenomenon, perhaps a local form of angioneurotic edema appears to be the most likely etiologic factor.

It is well known that acute scrotal swelling in children may be due to such conditions as traumatic hematocele, torsion of the testis, appendix testis, epididymo-orchitis, and incarcerated inguinal hernia. However, there is a lesser known entity which in our experience is fairly common and needs consideration, namely idiopathic scrotal edema. In one series it accounted for 20 per cent of cases of acute scrotal conditions.’ A typical case exhibits the following features. There is usually a one-day history of sudden onset of unilateral or bilateral erythema and edema of the scrotum which is minimally tender and which frequently extends onto the anterior abdominal wall and into the perineum. The child is afebrile with a normal urinalysis, sterile urine, and a normal white blood cell count. In some cases eosinophilia may be present. The cord and testis are usually found to be normal on palpation. When diagnostic uncertainty exists, surgical exploration of the scrotum reveals a normal testis and epididymis, but the scrotal wall is very edematous. Culture of the subcutaneous tissue is sterile. Characteristically the clinical findings resolve in one to two days regardless of the form of management employed (Fig. 1). Many causes have been postulated for this condition including perianal infection, streptococcal cellulitis, trauma, and allergic processes,

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but none has been well substantiated.le5 To draw attention to this condition we have reviewed the experience of a large children’s hospital over an eight-year period. Clinical

Material

Thirty episodes of idiopathic scrotal edema seen in 26 patients at the Alder Hey Children’s Hospital over an eight-year period constitute the basis of this study. The age range was from two to eleven years, but 60 per cent were between four and six years of age. Recurrent attacks were rare with only 3 patients having subsequent episodes. However, 1 child had three attacks within one year. No seasonal variation could be demonstrated. The symptoms had been present for less than twenty-four hours in 29 of 30 cases. The most common complaint was swelling of the scrotum which was found in all cases. Pain, generally mild, was a feature in 66 per cent of this group. Urinary and rectal symptoms were rare. Two patients gave a history of trauma and one a history of drug allergy. Only 1 child had a marginally elevated temperature. On clinical examination, scrotal swelling and erythema were more common on the left than the right side but were bilateral in one third of the patients. Approximately two thirds of the cases had extension of edema onto the abdominal wall in the inguinal region or into the

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FIGURE 1. (A) Close-up photograph showing bilateral edema of scrotum. (B) Lines outline extent of edema up onto anterior abdominal wall and down into perineum. (C) Complete resolution of edema three days after onset and without any treatment.

perineum. Scrotal tenderness was present in two thirds of the patients. Only 3 boys had subcutaneous ecchymosis possibly indicative of trauma. Although one child had abrasions of the knee on the side of the scrotal edema, none of the patients had ipsilateral inguinal adenopathy. Laboratory

investigations

Half the patients had urinalysis and urine culture performed. The urine was consistently sterile, but 1 boy had some white blood cells in the urinary sediment. Of the 8 patients who had white blood cell counts performed, 6 fell between 6 and 8,000 per cubic millimeter, and 2 had counts of 11,000 per cubic millimeter. There was no shift to the left in any patient. However, 6 of the 8 patients had total eosinophi1 counts greater than 300 per cubic milli-

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meter. Three had counts __ ranging between 300 and 330 per cubic millimeter only. However, the 3 other patients had eosinophil counts which were considerably higher and ranged between 840 and 990 per cubic millimeter. Clinical

course

In 10 patients surgical exploration was performed because of diagnostic uncertainty, but only edema of the scrotal wall was detected. Half the patients were treated with antibiotics but had the same clinical course as those who did not receive any medication. In two thirds of the cases, the swelling had resolved within two days; in the remainder resolution had occurred by the fourth day. One third of the patients were followed up in the outpatient department, and all were noted to have completely normal genitalia.

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Comment In the differential diagnosis of acute swelling of the scrotum in children, idiopathic scrotal edema should be borne in mind. The marked subcutaneous edema and erythema which is only minimally tender and is associated with a normal testis and cord contrasts with the acutely tender testis seen in torsion of the testis or in epididymo-orchitis. Early torsion of the appendix testis is characterized by a small area of localized tenderness of the superolateral aspect of the testis which may progress to a tender diffuse swelling of the scrotum. Although these conditions may be confused with idiopathic scrotal edema, the characteristic feature of the latter condition is edema of the scrotum out of proportion to the degree of tenderness found. In traumatic hematocele there is usually a history of trauma although this may be difficult to elicit in a small child. In incarcerated hernia, there is an inguinal as well as a scrotal swelling which usually makes the diagnosis obvious. Idiopathic scrotal edema has been attributed to trauma, extension of perianal infection, streptococcal cellulitis, and allergy.lS5 In this and in previously reported series, the rarity of a history of trauma would appear to make this an unlikely explanation for most cases.lm5 Perianal disease in children in the form of anal fissures is common, but secondary cellulitis is rare.4 The history and clinical examination of patients in this and other series have failed to support the theory of perianal disease being a cause of idiopathic scrotal edema. Streptococcal cellulitis is characterized by an extremely tender hyperemic area of skin associated with a high fever and a significant leukocytosis.’ In our series we were unable to demonstrate any of these features. Furthermore, culture of the subcutaneous tissue both in this and other series have failed to grow any organisms.2,3,5 Resolution without antibiotic therapy has occurred within forty-eight hours in the majority of our patients, and it is unlikely that a streptococcal cellulitis would resolve so rapidly without antibiotic treatment. A local allergic phenomenon has been postulated as a cause of this condition, perhaps a form of angioneurotic edema. 1*3The occasional finding of eosinophilia would appear to support this theory. In our patient population, however, parasitic disease due to threadworms is not uncommon, and we are unable to exclude this as a contributory factor. The physical findings and clinical course

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of idiopathic scrotal edema bears a strong resemblance to angioneurotic edema. Angioneurotic edema is characterized by a localized painless swelling of the subcutaneous tissue or submucosa of various parts of the body. The overlying skin is usually normal in color and temperature, but it may be slightly reddened. There is no pain, and itching is rare. The chief sensation is one of distention. The individual lesion persists for one to three days and leaves no residual changes. Successive attacks may involve the same or different locations. Angioneurotic edema results from dilatation of the small blood vessels and transudation of fluid through the capillaries. The vascular changes are believed to result from a local derangement of permeability control possibly mediated by release of histamine, kinins, and other permeability factors. The triggering mechanism and predilection for a given site is not known. 6 It would seem possible that idiopathic scrotal edema is a variant of angioneurotic edema. The clinical course is short and benign, and therapy should consist of bedrest, reassurance, and perhaps a short course of antihistamines. By keeping this entity in mind, the urologist seeing a child with an acute scrotal swelling may avoid unnecessary surgical exploration Woodville Road EaIing Broadway London W5 2SE, England (MR. EVANS) ACKNOWLEDGMENT. The authors are grateful to Mr. J. H. Johnston for allowing them to report on the patients admitted to the hospital under his care and for his help and advice in the preparation of this article. References 1. QUIST, 0.: Swelling of the scrotum in infants and children, and nonspecific epididymitis. Study of 158 cases, Acta Chir. Stand. 110: 417 (1956). 2. ESSENHIGH, D. M., and STEWART, J. S. S.: Idiopathic scrotal oedema, Br. J. Surg. 53: 419 (1966). 3. HANSTEAD, B., and JOHN, H. T.: Idiopathic scrotal oedema of children, ibid. 36: 110 (1964). 4. MCKEE, W. M., DI CAPRIO, J. M., ROBERTS, C. E., and SHERRIS, J. C.: Anal carriage as a probable source of streptococcal epidemic, Lancet 2: 1007 (1966). 5. NICHOLAS, J. L., MORGAN, A., and ZACHARY, R. B.: Idiopathic oedema of scrotum in young boys, Surgery 67: 847 (1970). 6. SHERMAN,W. B.: in, Beeson, P. B., McDermott, W., Eds. : Textbook of Medicine, 13th ed., Philadelphia, W. B. Saunders Co., 1971, p. 801. 7. STOLLERMAN,G. H.: p. 515, op ~it.~

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